Clinical Rounds: Intrauterine Contraception: Current Evidence-Based Recommendations


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A 28-year-old nulliparous female presented to our family planning clinic for initiation of a new contraceptive method. Her past medical history was significant for chlamydial infection at age 20, which was successfully treated with antibiotics. Her family history was essentially unknown because she was adopted as an infant. She began menstruation at 12 years old, with regular periods occurring every 28 days, lasting between 4 and 5 days each. She had no history of pelvic inflammatory disease (PID), abnormal Pap smears, or known uterine abnormalities. She had her first sexual experience at age 17, and has had a total of six partners, two within the past year. She was not in a relationship at the time of the clinical encounter. She reported sexual partnership with men only. Her contraceptive history consisted of intermittent condom use from age 17 to age 20, followed by oral contraceptives with consistent condom use recently. She stated a desire for a nonhormonal contraceptive method. Upon questioning, she reported no desire to have children within the next 5 years. After discussing her contraceptive alternatives, she opted for a copper intrauterine device (IUD). She was tested for chlamydia and gonorrhea, and the results of both tests were negative. She returned to the clinic for IUD insertion the following week. At that time, she was advised that expulsion is the most likely cause of IUD failure, and is most common in the first 3 months of insertion, usually during menstruation.1 Instructions on how to check for the IUD and its threads were offered. She was instructed to assume the device had been expelled if she is unable to find the threads after menstruation, and that alternative contraception should be used until she is able to return to the clinic. Finally, she was informed of the signs and symptoms of pelvic infection and told to seek immediate medical care upon experiencing any of them, especially within the first 3 weeks following insertion.1 Upon returning to the clinic 4 weeks after insertion, she reported complete satisfaction with the method. She was reminded that menstrual abnormalities, including spotting or longer menstrual periods, are common in the first 3 to 6 months of use, but that any serious abnormalities in her bleeding pattern after 6 months should be reported.1